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...Cancer  and  the  public  health, 

RC261  Am321  1916 


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Cancer  and  the  Public  Health 


Addresses  delivered  at  a  meeting  for  health  officers,  January  29, 

1916,  arranged  by  the  Boston  Local  Committee  of  the 

American  Society  for  the  Control  of  Cancer 


BY 


FRANCIS  CARTER  WOOD,  M.   D. 

Director  of  Cancer  Research 

George  Crocker  Special  Research  Fund 

Columbia  University,  New  York 

EDWARD  REYNOLDS,  M.  D. 
Chairman  of  the  Boston  Local  Committee 

Vice-president  of  the 
American  Society  for  the  Control  of  Cancer 

EUGENE  R.  KELLEY,  M.  D. 

Director  of  Division  of  Communicable  Diseases 

Massachusetts  State  Department  of  Health 


PUBLICATIONS  OF  THE 
AMERICAN  SOCIETY  FOR  THE  CONTROL  OF  CANCER 

105  EAST  22ND  STREET,  NEW  YORK 
Bulletin  9  March,  1916 


Cancer  anti  tije  public  2|ealti) 

Addresses  Delivered  Before  the 

BOSTON  LOCAL  COMMITTEE 

OF  THE 

American  i&otitty  for  tije  Control 
of  Cancer 


BY 

FRANCIS  CARTER  WOOD,  M.  D. 

Director  of  Cancer  Research 

George  Crocker  Special  Research  Fund 

Columbia  University,  New  York 

EDWARD  REYNOLDS,  M.  D. 

Chairman  of  the  Boston  Local  Committee 

Vice-president  of  the 
American  Society  for  the  Control  of  Cancer 

EUGENE  R.  KELLEY,  M.  D. 

Director  of  Division  of  Communicable  Diseases 

Massachusetts  State  Department  of  Health 


JANUARY  29,  1916 


Tfczw 


CANCER  AND  THE  PUBLIC  HEALTH 

FRANCIS  CARTER  WOOD,  M.  D. 

It  is  always  a  peculiar  pleasure  for  me  to  appear  in 
Boston,  for  I  have  many  friends  here  who  are  interested 
in  the  questions  upon  which  I  am  to  speak  to-day.  I 
am  also  glad  to  address  the  members  of  the  State  Board 
of  Health  and  the  visiting  nurses  who  come  in  contact 
with  many  of  the  unfortunates  in  whom  cancer  has  gone 
beyond  the  stage  of  cure ;  and  it  is  an  additional  pleasure 
to  represent  the  American  Society  for  the  Control  of 
Cancer,  which  is  a  rather  recent  organization  devoted 
wholly  to  the  propaganda  for  controlling  cancer  by  in- 
sisting on  its  curability  by  early  operation,  its  wide- 
spread occurrence,  and  other  interesting  and  important 
facts  which  the  public  should  know.  In  the  United 
States  we  are  very  particular  about  our  animals ;  we  pre- 
vent the  farmer  from  keeping  a  cow  with  tuberculosis; 
but  we  allow  the  head  of  a  family  to  keep  children  with 
as  many  diseases  as  they  care  to  collect.  We  regulate 
our  animal  population;  but  we  neglect  the  human  race. 
What  the  publicists  and  health  officers,  however,  are  now 
trying  to  da  is  not  to  regulate  too  much,  not  merely"  to 
pass  laws,  because  laws  are  of  very  little  importance  un- 
less people  have  intelligence  enough  to  understand  the 
reason  for  the  laws,  and  hence  to  obey  them  willingly; 
but  to  educate  the  public  on  this  subject  of  cancer. 

Now,  why  are  we  all  so  interested  in  cancer?  Why  was 
this  American  Society  for  the  Control  of  Cancer  started? 
The  reason  is,  I  think,  that,  in  the  first  place,  cancer 
touches  every  one  of  us,  because  it  is  a  disease  which 
strikes  quietly  and  without  warning  at  those  for  whom 
we  care  the  most.  It  strikes  our  parents,  our  friends,  as 
they  get  to  middle-age,  since  cancer  is  a  disease  most 


prevalent  after  the  age  of  forty,  and,  therefore,  touches 
people  in  the  full  strength  and  vigor  of  their  liveSj  people 
at  their  most  useful  period;  and,  in  the  second  place,  it 
is  hopeless,  absolutely  hopeless,  if  it  goes  too  far.  That 
is  one  of  the  sad  things  about  cancer — the  very  hopeless- 
ness of  it.  There  is  always  hope  in  tuberculosis;  the 
patient  himself  is  cheerful  over  his  trouble;  there  is  the 
possibility  of  cure.  But  when  cancer  goes  too  far,  there 
is  no  cure ;  and  yet  the  mind  remains  clear  and  the  slow 
progression  of  the  disease  makes  prominent  the  peculiarly 
bitter  aspect  of  this  condition.  The  importance  of  realiz- 
ing that  every  second  lost,  in  deciding  whether  the  patient 
has  or  has  not  cancer,  renders  the  final  chance  for  cure 
just  so  much  less,  is  beginning  to  be  appreciated.  The 
practicing  physician  has  in  the  past  been  held  responsible 
for  the  spreading  of  information  concerning  cancer;  but 
the  physician  individually  is  a  very  busy  man,  and  if  he 
graduated  thirty  years  ago,  he  does  not  know  quite  so 
much  about  cancer  as  he  might.  The  duty  of  publicity 
is  to-day,  therefore,  falling  more  and  more  into  the  hands 
of  the  health  officer;  and  it  is  quite  properly  the  health 
officer  who  should  take  up  the  cancer  problem  and  help 
in  the  transmission  of  information,  because,  after  all, 
the  future  of  medicine  is  in  prevention,  and  that  future 
belongs  to  the  officer  of  health.  Just  think  what  has 
been  done  in  twenty  years  in  the  reduction  of  diphtheria; 
think  that  if  every  person  would  take  typhoid  vaccine, 
there  would  be  no  more  typhoid  fever;  that  if  everyone 
with  tuberculosis  could  be  properly  isolated,  there  would 
be  no  more  tuberculosis;  that  if  only  the  laws  which  we 
now  have  concerning  the  transmission  of  disease  could 
be  intelligently  enforced  and  regulated,  almost  all  of  the 
infectious  diseases  would  disappear. 

In  looking  over  the  latest  manual  on  the  duties  of 
health  officers,  by  MacNutt,  I  find  much  concerning  san- 
itation and  general  hygiene,  but  absolutely  no  mention 
of  the  subject  of  cancer;  and  yet  the  time  has  unquestion- 
ably come  when  this  particular  subject  is  to  be  of  a  great 


deal  of  importance  to  officers  of  health.  The  reason  is 
not  far  to  seek.  There  are  three  stages  in  the  development 
of  any  science,  including  sanitation;  one,  of  laboratory 
or  clinical  investigation,  often  by  persons  who  are  not 
in  any  way  connected  with  the  work  of  public  health,  on 
the  nature  of  disease,  and,  in  some  cases,  on  its  preven- 
tion and  cure;  two,  the  transmission  of  this  knowledge 
to  the  medical  profession  or  the  modern  specialist  in 
hygiene ;  three,  and  this  is  the  important  function  of  the 
officer  of  health,  the  teaching  of  such  portions  of  this 
knowledge  as  are  suitable  for  the  lay  public,  to  the  people 
of  the  state,  or  town,  or  county  which  the  health  officer 
serves.  This  is  the  last  phase.  The  cancer  question  has, 
to  a  certain  extent,  reached  this  point. 

The  laboratory  investigations  of  the  last  twenty  years 
have  added  much  to  our  knowledge  of  cancer;  but  they 
have  also  brought  forward  one  point  very  clearly,  and 
that  is,  that  for  most  cancers  there  is  at  the  present  time 
no  certain  cure  except  the  prompt  removal  of  the  growth. 
It  is  very  important  that  the  public  should  be  informed 
in  definite  and  simple  manner  of  this  very  important 
fact.  Only  the  future  can  bring  forth  any  cure,  if  such 
a  cure  is  to  be  obtained  by  medical  means ;  but  physicians 
are  still  ignorant  of  the  fact  that  in  its  early  stage  the  dis- 
ease is  curable  by  operation.  Too  often  in  the  smaller 
towns  and  in  the  country  villages  we  see  cases  of  cancer 
which  have  been  allowed  to  become  hopeless  owing  to 
the  application  of  palliative  methods,  though  at  the  time 
when  they  were  first  seen  they  were  wholly  operable. 
The  profession  is  much  more  to  be  blamed  in  this  regard 
than  the  public,  for  medical  men  have  the  means  and 
should  inform  themselves  of  modern  knowledge  concern- 
ing the  excellent  operative  results  which  are  obtained  in 
the  early  removal  of  tumors.  In  fact,  however,  I  think 
it  may  safely  be  said  that  in  the  larger  cities  the  public 
in  general  is  better  educated  than  many  physicians  who 
graduated  thirty  years  ago.  Some  of  these  physicians  do 
not  take  kindly  to  the  suggestion  that  they  return  to  their 


medical  schools  and  again  take  up  the  study  of  certain 
phases  of  their  profession;  and  it  is  difficult  to  get  busy 
men  to  leave  their  practices  even  to  take  short  courses  of 
only  six  weeks,  such  as  are  offered  by  the  Harvard  Medi- 
cal School  in  the  summer  session,  or  by  the  various  post- 
graduate schools  in  the  larger  cities.  The  demands  of 
practice  are  so  great,  and  the  rewards  of  such  practice  in 
a  financial  sense  so  little,  that  these  men  cannot  afford 
the  time  and  money  necessary  for  any  extra  study.  If 
they  do,  they  are  more  apt  to  take  up  some  practical  thing, 
such  as  the  development  in  surgical  technique  or  in  other 
fields  of  immediate  usefulness,  rather  than  a  rather  ab- 
stract or  laboratory  subject.  These  physicians  are  the 
very  people  who  need  education  by  the  public  health 
officers,  either  through  personal  contact,  or  by  the  giving 
of  public  lectures  suitably  illustrated,  by  the  circulation 
of  pamphlets  or  leaflets,  or  by  similar  means.  For,  unfor- 
tunately, the  average  busy  practitioner  does  not  at  the 
present  time  read  very  much  in  the  standard  medical 
publications,  such  as  the  Journal  of  the  American  Medi- 
cal Association.  The  fact  has  been  shown  that  not  half 
the  country  doctors  of  some  of  the  States  even  subscribe 
to  such  a  journal;  almost  all  their  reading  seems  to  con- 
sist of  the  perusal  of  cheap  magazines  issued  frequently 
by  the  firms  who  are  selling  more  or  less  doubtful  medi- 
cines, very  many  of  them  quack  remedies  for  the  cure 
of  cancer. 

Public  health  officials  have  two  very  important  oppor- 
tunities in  relation  to  this  disease;  one,  the  supervision 
and  study  of  the  records  of  large  numbers  of  cases  from 
a  statistical  point  of  view;  and,  two,  the  education  of  the 
public  by  bulletins,  lectures,  or  demonstrations,  preferably 
in  collaboration  with  county  or  State  medical  societies. 

What  we  know  about  cancer  to-day  is  relatively  small 
in  amount,  and  there  are  many  problems  for  the  elucida- 
tion of  which  further  data  are  needed.  Some  of  these 
questions  may  be  solved  by  laboratory  experiments  on 
animals,  many  others  require  statistics  of  human  cases. 


The  collection  of  such  data  must  be  begun  now  in  order 
that  the  material  may  be  ready  for  final  study  ten  or 
twenty  years  from  to-day.  That  our  statistics  are  now 
extremely  defective  is  generally  acknowledged.  The  Cen- 
sus Bureau  has  had  to  send  some  37,000  letters  to  physi- 
cians asking  that  they  make  fuller  and  more  accurate 
returns  in  cases  of  cancer,  but  even  should  these  records 
be  completed  as  requested,  the  data  so  available  would  be 
far  behind  those  of  many  European  countries.  The  sta- 
tistics of  hospitals  alone  are  of  but  little  value,  because 
they  cover  only  a  selected  material,  and  cannot  be  con- 
sidered as  accurately  representing  the  normal  population 
of  the  district  in  which  the  institution  is  situated.  Such 
statistics  give  us  only  the  proportions  between  the  kinds 
of  cancer  which  occur,  and  do  not  even  furnish  anything 
of  final  value  concerning  organ  distribution;  since,  for 
example,  a  disproportionate  number  of  patients  with  can- 
cer of  the  stomach,  or  of  the  breast,  or  of  any  other 
organ,  may  be  attracted  to  a  hospital  because  of  the  repu- 
tation of  a  particular  surgeon  as  an  expert  operator  on 
the  malignant  growths  of  each  region.  There  is  a  con- 
crete illustration  of  this  in  the  large  number  of  thyroid 
tumors  operated  upon  at  the  Mayo  Clinic  at  Rochester, 
Minnesota.  The  real  need  is  for  accurate  statistics  by 
counties,  as  well  as  by  States,  in  order  that  it  may  be 
determined  whether  there  is  any  local  variation  in  the 
different  portions  of  a  State,  due  possibly  to  the  influence 
of  climatic  conditions,  soil,  moisture,  drainage,  etc.,  on 
the  occurrence  of  cancer.  To  secure  valuable  statistical 
results,  however,  there  must  also  be  the  collection  of 
accurate  census  information  as  to  the  general  population 
of  the  district,  and  the  age  and  sex  distribution;  and  in 
many  States  such  information  has  not  yet  been  obtained. 
When  these  data  are  once  recorded,  they  can  be  used  for 
larger  purposes  and  are  available  for  the  publications  of 
the  Census  Bureau. 

The  popular  view  that  "cancer  States,"  "cancer  dis- 
tricts" or  "cancer  villages"  exist  has  unfortunately  been 


fostered  by  physicians  unacquainted  with  statistical 
methods.  Much  has  been  done  in  England  by  the  Imper- 
ial Cancer  Research  Fund  and  by  the  Registrar  General 
in  their  reports  to  explain  the  occurrence  of  large  num- 
bers of  cases  of  cancer  in  certain  districts  by  a  study  of 
the  age  distribution  therein.  Cancer  being  a  disease  of 
advanced  life,  it  is  usually  found  that  such  districts  con- 
tain a  large  proportion  of  older  people.  In  this  country 
this  is  particularly  marked  in  the  New  England  States, 
Vermont  and  New  Hampshire  especially  having  high 
cancer  death  rates ;  and  the  condition  here  can  be  ascribed 
chiefly  to  the  drift  of  the  younger  population  to  the  large 
cities  outside  of  these  States,  and  not  to  inbreeding  or 
greater  liability  of  the  inhabitants  themselves. 

The  interest  of  public  health  officials  in  occupational 
diseases  is  now  widespread,  and  it  is  of  the  utmost 
importance  that  any  correlation  between  a  particular 
occupation  and  the  occurrence  of  cancer  be  carefully 
investigated.  It  is  well  known  that  the  workers  in  brass 
foundries  are  liable  to  cancer  of  the  upper  extremities, 
chimney  sweeps  and  briquette  workers  to  cancer  of  the 
scrotum,  those  employed  in  the  manufacture  of  certain 
synthetic  coal  tar  products  to  cancer  of  the  bladder,  and 
x-ray  operators  to  cancer  and  leukemia;  but  there  are 
many  occupations  concerning  which  no  information  of 
this  sort  is  as  yet  available,  and  this  can  be  obtained  only 
through  the  authority  of  State  Boards  of  Health  and  with 
the  concurrence  and  active  interest  of  health  officials. 
The  importance  of  records  of  this  sort  in  determining  the 
rates  for  industrial  insurance  and  workingmen's  compen- 
sation is  obvious,  though  apart  from  the  cancer  problem. 

Writers  differ  greatly  in  their  published  statements 
concerning  the  correlation  between  trauma  and  malig- 
nant disease.  The  tendency  in  the  past  has  been  to  as- 
sume that  even  a  single  injury  may  cause  a  cancer;  but 
recently  this  view  has  been  challenged  from  many  sides 
and  it  is  now  generally  believed  that  a  single  injury, 
unless  it  produces  prolonged  ulceration,  as,  for  example, 


an  x-ray  or  metal  burn,  is  of  little  importance  in  the 
genesis  of  cancer;  it  is  thought  rather  that  only  long 
continued  irritations  extending  into  adult  life,  that  is, 
into  the  period  of  susceptibility  to  cancer,  are  of  any 
influence.  The  medico-legal  interest  in  these  facts  needs 
no  consideration  here.  With  the  data  which  will  accumu- 
late from  the  records  of  the  Employers'  Liability  laws,  it 
may  not  be  impossible  to  cast  some  light  upon  this  sup- 
posed relationship  within  the  next  twenty  years,  but  the 
work  must  be  started  now  in  order  that  sufficient  facts 
be  available  later. 

With  the  increase  in  the  laws  regarding  notification 
for  venereal  disease,  and  the  general  employment  of  the 
Wassermann  test,  it  is  beginning  to  be  possible  to  study 
the  relationship  between  cancer  and  syphilis.  So  far, 
attention  has  been  directed  in  this  connection  chiefly  to 
cancer  of  the  tongue,  which  seems  often  to  have  a  syph- 
ilitic basis.  In  addition,  the  relationship  between  cancer 
and  syphilis,  and  between  cancer  and  the  excessive  use 
of  alcohol  and  of  tobacco  can  be  studied  much  better  from 
broad  general  statistics  than  from  the  collection  of  small 
numbers  of  cases  such  as  pass  under  the  observation  of 
the  individual  surgeon. 

While  there  is  little  reason  at  the  present  time  to  be- 
lieve that  heredity  plays  an  important  part  in  the  occur- 
rence of  cancer,  yet  certain  experiments  in  breeding  mice, 
as  for  instance  those  carried  out  by  Dr.  Tyzzer  of  the 
Cancer  Commission  of  Harvard  University,  have  sug- 
gested that  in  these  animals  at  least,  and  in  certain  strains 
only,  cancer  may  be  subject  to  the  laws  of  heredity.  That 
these  observations  apply  to  human  beings  is  doubtful, 
for  they  are  not  observed  in  other  strains  of  animals,  or 
even  in  all  breeds  of  mice,  and  the  question  can  be  settled 
only  by  very  extensive  statistical  studies  on  man,  which 
are  of  much  more  final  value  than  breeding  experiments 
in  animals.  A  physician  unacquainted  with  statistical 
methods  may  observe  three  cases  in  one  family  and, 
therefore,  conclude  that  it  is  hereditary.     I  remember 


10 

talking  with  a  very  delightful  old  Southern  surgeon  who 
told  me  of  an  instance  that  proved  cancer  to  be  hereditary 
in  certain  families.  This  same  surgeon  was  very  fond 
of  certain  occupations,  and  he  used  to  take  great  pleasure 
in  spending  hours  waiting  for  a  combination  of  four  aces 
to  appear  in  a  hand  of  cards.  When  he  got  this  combina- 
tion he  did  not  think  it  was  hereditary;  he  thought  it  was 
good  luck!  The  same  law  applies  in  the  cancer  problem 
to  the  finding  of  three  or  four  cases  of  the  disease  in  one 
family.  In  any  community  of  several  thousand,  the  prob- 
able proportion  of  cancer  can  be  worked  out  mathemati- 
cally. The  occurrence  of  two  or  three  cases,  therefore, 
in  a  family  does  not  necessarily  mean  that  cancer  is 
hereditary.  Such  information  of  fair  accuracy  as  may 
be  obtained  might,  however,  be  made  a  part  of  the  death 
certificate. 

While  the  fatal  nature  of  cancer  and  its  frequent 
occurrence  are  quite  sufficient  to  keep  alive  a  very  potent 
interest  in  the  cancer  question,  apart  from  any  considera- 
tion of  whether  it  is  increasing  or  decreasing,  such  possi- 
ble variation  should  be  studied;  first,  because  of  its  casting 
some  light  on  the  cause  of  the  disease;  and,  second,  be- 
cause of  its  practical  importance  as  necessitating  (if  there 
be  an  increase)  more  frequent  operative  removal  or  medi- 
cal treatment  of  such  moles,  senile  keratoses,  or  chronic 
ulcers  as  are  apt  to  turn  into  cancer.  Unfortunately,  it  is 
impossible  at  the  present  time  to  make  a  definite  statement 
as  to  any  increase.  So  many  conflicting  factors  are  pres- 
ent that  the  statistical  data  do  not  as  yet  furnish  a  final 
decision.  Equally  able  men  hold  that  there  is  a  demon- 
strable increase,  and  that  there  is  none.  In  this  situation 
the  only  remedy  is  the  improvement  of  our  mortality 
records,  and,  however  carefully  these  may  be  collected, 
they  will  never  be  of  final  value  unless,  first,  autopsies 
are  performed  upon  all  those  dying  of  disease,  whether 
supposed  to  be  cancerous  or  not,  and,  second,  microscopic 
examinations  are  made  of  the  suspected  tissues.  If  these 
could  be  done,  and  the  varieties  of  tumors  also  deter- 


11 

mined,  many  of  the  questions  now  apparently  insoluble 
would  be  answered  in  a  couple  of  decades.  For  besides 
knowing  whether  cancer  on  the  whole  is  increasing,  we 
must  also  learn  whether  one  variety  or  another  is  becom- 
ing more  frequent,  or  whether  the  organ  frequency  is 
changing.  Bashford's  investigation  of  the  London  Hospi- 
tal records  showed  that  autopsies  and  microscopic  exam- 
inations increased  the  number  of  diagnosticated  cancers 
by  some  thirty  per  cent. 

These  microscopic  methods  are  too  complex  and  too 
time-consuming  for  the  practitioner,  even  if  he  had  suf- 
ficient knowledge  to  make  a  diagnosis  when  the  sections 
were  prepared;  which  he  has  not.  The  State,  therefore, 
should  offer  the  facilities  for  diagnosis,  and  when  they 
are  offered,  should  require  the  submission  of  suitable 
specimens  from  all  cases  considered  cancerous. 

The  discussion  of  the  second  phase  of  public  health 
activities  will  occupy  the  remainder  of  our  time.  As  has 
been  said  there  is  no  question  that  the  public,  and  even 
physicians  whose  medical  degrees  date  back  more  than 
twenty  years,  are  in  many  cases  woefully  ignorant  of 
the  fact  that  when  a  cancer  can  be  diagnosed  clinically 
with  any  ease  it  is  already  approaching  an  inoperable 
condition.  There  is  still,  not  only  in  rural  districts  but 
also  in  the  large  cities,  an  extraordinary  amount  of  ignor- 
ance concerning  the  nature  and  treatment  of  cancer. 

Let  me  read  you  a  letter  just  received  from  an  illiterate 
gentleman  in  Kansas,  and  a  parallel  statement  recently 
published  by  a  physician  of  reputation: 

Jan.   the  24,  A.   D.   1916. 
dr  francis  carter  wood 

Dear  sir  I  see  an  account  in  the  star  that  thare  is  no  cure  has 
ever  bin  found  yet  you  are  badly  mistaken  I  have  A  cure  for 
cancers  I  no  this  I  have  tested  it  I  tell  you  the  truth  and  nothing 
but  the  truth  I  can  cure  cancer  of  the  stomich  you  can  eat  my 
salve  It  will  not  hurt  you  Mr  wood  you  say  thare  is  3  million  dol- 
lar fund  left  for  any  man  that  has  a  cancer  cure  I  have  the  onley 
cure  on  earth  Dear  sir  I  am  not  a  student  nor  a  doctor  but  if  you 
stack  up  3  million  dollars  so  it  is  mine  when  the  cancer  is  cured  bring 


12 

on  your  man  or  woman  I  do  not  care  how  Bad  thare  ate  up  if  the 
flesh  is  all  gon  off  arm  or  leg  or  grate  holes  eat  out  But  take  a  cancer 
when  it  is  as  big  as  half  dollar  it  wont  make  a  bad  scar  dear  sirs  I 
am  ready  to  go  to  work  Bring  the  patient  and  check,  put  it  in  the 
bank  so  it  is  mine  when  cancer  is  cured 
From  J.  M.  Brown, 

Barlington,   Kans. 
answer  at  once 

Would  it  be  wise  to  permit  an  illiterate  of  this  type 
to  treat  a  member  of  your  family?  Yet  most  cancer  quacks 
seem  to  be  just  about  as  well  educated  as  Mr.  Brown. 

The  physician  says  that  he  has  clinical  and  statis- 
tical facts  to  show  that  carcinoma  is  an  infection.  The 
germ  is  found  in  the  surface  soil  and  dirt  of  populous 
districts  and  enters  the  system  in  the  majority  of  cases 
with  the  food.  By  way  of  prophylaxis  he  recommends : 
That  carcinoma  should  be  considered  an  infectious  dis- 
ease. That  fruits  and  vegetables  should  be  sterilized  be- 
fore being  eaten.  That  the  use  of  human  excrement  as 
fertilizer  should  be  prohibited  by  law.  That  people  should 
be  taught  the  infectious  nature  of  normal  stools ;  and  that 
women  should  be  taught  to  spend  a  considerable  portion 
of  their  time  washing  their  hands  (perhaps  instead  of 
powdering  their  noses).  That  the  number  of  cats  and 
dogs  should  be  restricted.  That  rats,  mice,  cockroaches, 
and  other  vermin  should  be  exterminated.  That  all  work- 
ers should  wash  their  hands  very  thoroughly  before  eat- 
ing, and  should  wash  and  disinfect  their  hands  very 
thoroughly  and  change  their  working  garments  when 
they  leave  their  work  for  the  day.  That  municipal  author- 
ities should  put  carcinoma  on  the  list  of  diseases  to  be 
reported  in  order  that  the  patients  may  be  traced  and 
taught  how  to  take  care  of  themselves  and  their  infected 
discharges,  and  that  none  of  those  living  with  them  be 
allowed  to  handle  foodstuffs  for  the  market.  That  as  the 
time  seems  ripe  the  public  should  be  taught  something 
concerning  the  erroneous  notions  about  diet  that  are  prev- 
alent among  the  idle  rich  and  the  prosperous  poor  in 
order  that  they  may  stop  manufacturing  the  serious  forms 


13 

of  gastrointestinal  disease  that  have  of  late  years  shown 
such  an  alarming  increase  in  frequency,  the  seeds  of 
which  are  sown  in  adolescence  and  the  fruits  of  which 
are  harvested  at  maturity  and  senescence.  That  women 
who  have  not  borne  children  for  several  years  should 
be  warned  of  the  danger  of  developing  carcinoma. 

Very  good  general  advice,  some  of  this,  but  hardly 
connected  with  cancer  or  its  cure.  Cancer  is  certainly 
not  due  to  a  germ,  and  it  is  certainly  not  contagious. 

Is  it  necessary  to  discuss  any  further  the  need  for 
widespread  education?  There  is,  evidently,  both  in  rural 
and  in  urban  practice,  too  much  palliative  treatment  of 
cancer  with  salves  and  plasters,  which  keeps  the  patient 
from  consulting  a  surgeon  until  the  growth  has  gone 
beyond  the  operable  stage.  It  must  be  remembered,  how- 
ever, that  it  is  only  within  the  past  twenty  years  that  the 
fact  has  been  recognized  that  in  its  early  stages  cancer 
is  a  local  disease  and  may  be  removed  surgically  with 
great  likelihood  of  a  permanent  cure ;  hence,  we  can  not 
be  too  harsh  with  ignorance  on  this  point  among  the 
members  of  the  profession  and  the  lay  public. 

The  duty  of  health  officers  is  plainly  along  the  line 
of  publicity.  The  average  busy  practitioner  has  no  time 
nor  ability  to  present  interesting  and  valuable  facts  in 
simple  language,  and  if  he  is  quoted  in  the  daily  press 
he  is  often  criticised  for  advertising.  As  the  health  officer 
usually  does  not  practice,  and  at  any  rate  is  not  wholly 
dependent  upon  his  practice,  he  can  use  the  press  much 
more  freely.  The  value  of  information  given  in  simple 
language  and  without  hysteria  and  exaggeration  is  enor- 
mous. Of  course,  the  journalist  always  wants  a  "story", 
but  if  he  is  furnished  with  an  interesting  statement  in 
untechnical  phrases,  is  given  a  little  help  in  working  up 
his  paragraph,  and  is  warned  that  any  misquotation  will 
cut  him  off  from  a  further  supply  of  news,  it  will  gener- 
ally be  found  possible  to  gain  his  sympathy  and  coopera- 
tion so  that  he  will  publish  only  perfectly  sane,  unsensa- 
tional   articles.    After  all,  these  men  are  engaged  in  the 


14 

business  of  collecting  news,  and  they  are  grateful  for 
every  opportunity.  The  daily  papers  are  very  sensitive 
to  criticism  and  are  only  too  glad  of  accurate  news.  A 
great  deal  of  objectionable  matter,  which  had  been  pre- 
pared for  the  columns  of  one  of  the  great  New  York 
dailies  by  a  member  of  the  staff,  was  recently  cut  out 
by  the  owner  of  the  paper  at  the  request  of  a  few  medical 
men  who  represented  to  him  the  damage  which  he  was 
doing  by  the  widespread  distribution  of  notices  of  quack 
cures  for  cancer  and  other  diseases,  notices  which  really 
should  have  gone  into  the  advertising  columns  and 
contributed  thousands  of  dollars  to  the  profits  of  his 
paper — or,  rather,  should  never  have  been  received  at  all. 
In  addition  to  the  publication  of  articles  in  the  daily 
press,  health  bulletins  should  be  prepared  and  widely 
circulated.  The  Department  of  Health  of  the  City  of 
New  York  publishes  a  very  valuable  weekly  pamphlet, 
and  the  State  Department  of  Health  an  equally  valuable 
monthly,  which  contains  articles  by  well  known  phy- 
sicians on  the  special  subjects  on  which  they  are 
authorities.  In  addition  to  issuing  such  printed  matter, 
health  officers  should  combine  with  County  and  State 
Societies  in  giving  lecture  courses,  illustrated  by  lantern 
slides  showing  the  appearance  of  cancers  in  early  stages, 
and  with  demonstrations  of  suitable  pathological  speci- 
mens. Such  talks  are  of  great  educational  value  to 
the  layman  and  to  the  physician  as  well ;  and  campaigns 
of  education  of  this  sort  should  be  conducted  by  health 
officers  and  repeated  at  frequent  intervals  so  that  their 
lessons  may  not  be  forgotten.  Health  officers  should 
always  be  prepared  also  to  discuss  sanitary  matters  with 
individuals.  There  are  so  many  people  who  are  afraid 
of  a  cancer  patient  because  of  their  dread  of  contagion; 
others  worry  endlessly  because  of  newspaper  articles 
concerning  heredity  or  "cancer  villages"  which  they 
have  read  and  misinterpreted.  A  word  here  and  there 
to  these  people  is  not  seed  cast  upon  stony  ground;  they 


15 

talk  to  their  friends  and  spread  the  news,  often  to  an 
astonishing  degree. 

A  great  many  people  think  cancer  is  contagious.  I 
am  getting  letters  all  the  time  from  women  who  write: 
"My  mother  has  a  cancer;  ought  I  to  take  care  of  her, 
and  ought  the  children  to  be  allowed  in  the  room?" 
There  is  absolutely  no  reason  to  think  that  cancer  is 
contagious.  There  has  never  been  so  far  as  I  know  a 
definite  record  of  any  case  of  contagion  from  one  person 
to  another.  If  cancers  were  contagious,  the  surgeons 
who  are  operating  daily  would  certainly  contract  the 
disease.  The  same  is  true  of  the  possibility  of  infection. 
There  is  as  I  have  said,  no  proof  that  cancer  is  due  to 
a  germ. 

The  prompt  and  highly  gratifying  results  of  such 
an  educational  campaign  have  been  shown  in  several 
localities  recently  where,  following  lectures,  operative 
clinics,  and  demonstrations,  large  numbers  of  patients 
have  applied  for  treatment  at  the  different  hospitals. 
These  have  been  sent  in  by  physicians  who  had  pre- 
viously referred  but  few  cases  of  the  disease,  or  have 
come  from  localities  which  had  not  before  furnished 
such  material.  Bloodgood  has  recently  called  attention 
to  this  question  in  a  timely  article  in  the  Journal  of 
the  American  Medical  Association  (February  19,  1916.) 

In  closing,  it  cannot  be  repeated  too  often  that  every 
cancer  is  at  some  period  of  its  existence  curable  by 
operation.  The  only  difficulty  is  to  make  the  diagnosis 
early  enough.  There  is  no  certain  cure  for  all  kinds 
of  cancer  known  at  the  present  time,  except  cutting 
the  cancer  out.  While  radium  and  x-ray  unquestion- 
ably cure  a  small  number  of  early  cancers,  it  is  not 
possible  for  us  to  say  that  they  will  cure  all  kinds  of 
cancer,  and  they  should  not  be  used  in  the  treatment  of 
any  tumor  which  can  be  removed  by  operation  without 
jeopardy  to  the  patient's  life  and  health.  They  are 
without  question  the  best  means  for  the  palliative  treat- 
ment of  inoperable   or  recurrent  cases.    Nothing  else 


16 

has  the  slightest  influence  on  malignant  tumors.  None 
of  the  widely  advertised  serums,  bacterial  extracts,  or 
vegetable  emulsions,  such  as  "autolysin"',  none  of  these 
substances  cure  the  truly  malignant  forms  of  cancer. 

When  we  think  that  a  cancer  is  a  development  of 
the  body's  own  cells,  we  realize  that  to  destroy  a  cancer 
by  any  chemical  or  drug  means  also  to  destroy  the  organ 
from  which  the  cancer  arises.  People  will  tell  you 
that  there  must  be  some  remedy  for  cancer,  because 
there  is  a  remedy  for  malaria,  anemia,  or  syphilis;  but 
this  is  poor  logic.  Perhaps  we  never  shall  find  a  medical 
cure  for  cancer,  and  an  operation  will  always  remain 
the  best  form  of  treatment.  Preventive  methods  may  be 
discovered.    The  future  only  can  decide. 

The  duty  of  the  health  officer,  then,  is  to  spread 
through  the  community  such  facts  as  have  been  sifted 
and  studied  and  are  unassailable,  and  just  so  far  as  he 
does  this  he  is  fulfilling  his  most  important  function, 
for  after  all  the  law  is  of  little  value  unless  people  are 
educated  to  appreciate  its  meaning.  To  him  is  given 
the  opportunity  of  great  service  to  the  future  of  the  race. 


DISCUSSION 

EDWARD  REYNOLDS,  M.  D. 

Dr.  Reynolds  spoke  briefly  of  the  credentials  of  the 
American  Society  for  the  Control  of  Cancer,  and  stated 
the  proposition  which  the  Society  wished  to  put  before 
the  health  officers  of  the  State  with  regard  to  a  plan 
of  campaign,  explaining  in  what  manner  and  by  what 
means  the  Society  and  the  officials  could  be  of  mutual 
benefit  in  the  work. 

After  pointing  out  that  the  matter  of  dealing  with 
cancer  in  its  early  stages  was  no  longer  speculative 
but  one  of  assured  knowledge,  and  that  to  obtain  results, 
that  knowledge  must  be  spread  as  widely  as  possible, 
he  said: 


17 

"Now  what  can  health  bodies  do  about  that?  As 
Dr.  Wood  has  told  us,  health  officers  almost  practically 
control  space  from  their  local  press  because  what  a 
health  body  chooses  to  say,  the  local  press  will  publish, 
as  a  rule.  What  private  individuals  try  to  say  about 
cancer  is  often  not  news,  but  anything  that  comes  from 
the  Health  Department  is  news  because  they  are  taking 
it  up.  Of  course  the  health  officer  is  a  busy  man  and 
not  a  special  expert  on  cancer.  How  then  can  he  give 
that  information  to  the  press?  We  will  furnish  him 
with  material,  if  he  will  ask  for  it,  from  which  he  can 
select  what  his  local  press  will  publish.  We  have  a 
regularly  organized  information  service  for  health  offi- 
cers, and  if  any  health  officer  or  social  worker  will 
send  his  name  to  our  executive  office  and  ask  to  receive 
service  he  will  find  himself  in  prompt  receipt  of 
material  of  that  kind  for  local  press  use.  Many  Health 
Boards  of  the  country  are  taking  up  the  publication  of 
cancer  material  in  their  bulletins.  For  instance,  I  have 
here  one  published  by  the  West  Virginia  Public  Health 
Council,  one  from  North  Carolina,  and  one  from  the 
Michigan  State  Board  of  Health,  which  has  put  out  a 
cancer  number  containing  fourteen  articles  by  leading 
men  on  cancer;  and  there  is  also  a  leaflet  which  is  put 
out  by  the  Department  of  Health  of  Newark,  New  Jersey, 
for  circulation  among  the  less  intelligent,  while  South 
Orange,  New  Jersey,  a  little  village  really,  has  put  out 
an  excellent  cancer  leaflet  for  house  to  house  distri- 
bution. We  will  gladly  furnish  material  for  pamphlets 
for  such  distribution. 

Boards  of  Health  may  well  institute  lectures  on 
health  topics,  and  cancer  is  one  of  these.  Where  we 
can,  we  will  advise  by  sending  lecture  notes,  etc.;  in 
fact,  we  will  help  or  aid  as  far  as  we  can  by  suggesting 
lecturers,  or  by  furnishing  those  who  may  be  selected, 
with  lecture  notes  already  in  shape. 

Public  health  nurses  also  should  be  instructed  in 
the  latest  views  on  cancer.     No  one  is  more  apt  to  be 


18 

consulted  about  an  incipient  thing  than  the  nurse  who 
is  going  about  on  public  duty.  Nurses  will  be  sent 
any  of  these  pamphlets  if  they  will  ask  for  them,  and 
the  pamphlets  are  arranged  in  succinct  form  for  this 
purpose.  Remember  that  nurses,  expert  trained  nurses, 
have  been  in  touch  only  with  the  advanced  cases  that 
they  see  in  hospital  training;  they  do  not  know  the  incip- 
ient stages  of  the  disease,  so  they  are  the  people  of  all 
others  who  should  have  this  information,  coming  into 
contact  as  they  do  with  so  much  of  this  disease  among 
the  poor. 

That  is  the  point  which  I  wish  to  bring  out,  namely, 
our  readiness  to  furnish  material  for  publication, 
material  which  can  be  considered  authoritative  and 
which  is  in  form  for  lay  appreciation.  That  is  the 
proposition  which  we  put  up  to  you,  and  we  hope  that 
you  people  who  are  in  a  position  to  help  disseminate 
this  information  will  take  hold  and  spread  it  among 
the  public." 


EUGENE  R.  KELLEY,  M.  D. 

The  subject  has  been  so  thoroughly  covered  by  the 
previous  speakers  that  very  little  is  left  to  be  said 
from  the  stand-point  of  the  Health  Department  except 
to  register  our  appreciation  of  the  importance  of  the 
problem  and  our  readiness  to  do  whatever  is  in  our 
power.  I  may  say  that  I  had  prepared  some  notes  on 
the  statistical  side,  the  educational  side,  and  the  "judicial" 
side  of  the  subject,  but  the  previous  speaker  has  covered 
them  so  exhaustively  that  I  shall  spend  only  a  few  min- 
utes in  commenting  on  a  few  thoughts  that  came  to  me 
during  his  remarks. 

First  of  all,  there  are  certain  general  fundamental 
principles  of  health  administration  work  that  I  think 
are  not  always  borne  in  mind  by  the  propagandists 
or  people  working  exclusively  on  any  special  cause. 


19 

Another,  and  the  most  hopeful  thing  about  cancer 
campaigning,  is  the  fact  that  it  is  now  generally  admitted 
to  be  a  public  health  administrators'  problem.  A  few 
years  ago  that  point  was  not  grasped. 

Now  for  a  moment  let  us  disregard  cancer  as  a 
particular  problem  and  consider  what  a  Health  Depart- 
ment's position  is  as  regards  health  problems  en  masse. 
The  health  officials  must  give  thought  to  the  relative 
weight  of  any  individual  problem;  that  means:  how 
big  a  factor  is  it  in  the  mortality  returns?  This  point 
being  first  determined,  the  next  thing  is:  what  is  the 
prospect  of  immediate  returns  after  constructive  work 
is  done?  Next,  what  is  the  prospect  of  remote  returns? 
Then,  what  is  the  relative  availability  of  funds  for  this 
particular  purpose?  Assuming  that  there  :are  funds, 
what  is  the  relative  cost  of  doing  efficient  work?  And 
the  last  but  most  important  point  is:  how  great  is  the 
popular  demand  for  this  type  of  work?  Upon  that  will 
depend  the  amount  of  money  available  to  carry  it  on. 

What  then  is  the  relative  weight  of  the  cancer 
problem?  It  is  one  of  the  great  problems.  I  think  it 
is  an  almost  inescapable  fact  that  we  have  good  grounds 
for  believing  that  there  is  a  real  increase  in  cancer.  The 
figures  in  our  own  State  will  indicate  that.  I  doubt 
very  seriously  if  the  use  of  the  microscope  has  added 
anything  like  20  per  cent,  to  the  efficiency  of  diagnosis 
in  Massachusetts  since  1900.  Yet  the  rate  has  increased 
from  74.6  in  that  year  to  113  per  100,000  of  population 
in  1913.  There  is  also  a  great  increase  in  the  actual 
number  of  deaths;  from  2,183  in  1900,  to  3,197  in  1913, 
and  if  we  reflect  we  will  see  that  this  is  practically  in 
the  ratio  of  two  to  three.  The  population  during  the 
same  years  increased  at  the  rate  of  about  15  per  cent., 
so  even  allowing  for  the  increase  in  population,  there 
is  certainly  an  increase  of  somewhere  around  15  per 
cent,  in  cancer,  and  I  can  scarcely  believe  that  all  of 
that  is  apparent.  We  may  say,  then,  that  it  is  a  real 
problem  as  a  mortality  question.     It  rates  about  33  per 


20 

cent,  in  importance  as  compared  with  infant  mortality ; 
less  than  33  per  cent,  as  compared  with  organic  heart 
disease,  and  about  50  per  cent,  as  compared  with  tuber- 
culosis. On  the  other  hand,  it  is  important  to  remember 
that  cancer  is  an  old  age  problem.  Many  of  the  patients 
whose  death  certificates  are  made  out  as  cancer,  prob- 
ably would  very  soon  have  died  of  something  else, 
which  fact  is  all  important  to  remember  in  considering 
cancer  mortality  statistics,  and  in  all  attempts  to  estimate 
relative  absolute  life  saving  efficiency  of  any  line  of 
health  work. 

This  all  shows  the  way  the  Health  Department  has 
to  look  at  these  things.  Infant  mortality  is  the  greatest 
example  we  have  of  relatively  great  immediate  returns. 
It  has  well  been  called  the  bargain  counter  of  philan- 
thropy. In  that  branch  of  work,  a  small  amount  of 
money  plus  intelligent  direction  can  save  more  lives 
than  in  any  other.  Now,  somewhere  in  among  these 
problems,  I  think  perhaps  not  as  great  as  either  infant 
mortality  or  tuberculosis,  but  following  pretty  well 
after,  is  the  question  of  cancer. 

There  are  about  six  or  seven  simple  aphorisms  which, 
if  we  could  hammer  and  instil  them  into  all  the  active 
mental  processes  of  all  the  adult  citizens  of  our  country, 
would  reduce  the  fatality  of  cancer  probably  about  33 
per  cent.  This  sounds  simple ;  but  if  only  women  could 
be  taught  that  any  discharge  after  the  climacteric  is  seri- 
ous, and  that  any  lump  that  appears  after  thirty-five 
years  of  age,  should  be  examined,  we  would  be  doing 
something.  One  great  reason  why  it  is  so  hard  to 
educate  the  public  is  that  it  is  hard  to  rid  them  of 
another  aphorism,  an  old  one,  namely,  that  all  cancers 
are  hopeless.  To  eradicate  this  popular  fallacy  sounds 
easy,  but  it  is  not  quite  so  simple.  In  the  first  place, 
it  requires  money.  In  the  second  place  it  requires 
further  missionary  work  amongst  the  people  who  come 
forward  to  stand  sponsor  for  this  thing.  Organizations 
like  this  can  probably  persuade  our  legislative  bodies 


21 

that  this  is  a  legitimate  field  of  health  department  work. 
Probably  that  lesson  applies  somewhat  to  the  health 
departments  themselves. 

Now,  along  about  this  place  comes  up  the  question 
as  to  the  infallibility  of  the  Health  Department  in  relation 
to  the  public  press.  I  heartily  wish  that  we  might 
have  better  success  in  getting  good  articles  into  the 
newspapers.  The  principal  reason  that  we  fail  is  that 
we  lack  the  journalistic  training.  If  I  should  make 
any  criticism  of  these  excellent  pamphlets  that  are  pub- 
lished in  regard  to  cancer,  it  would  be  that  they  are 
written  too  much  along  the  plan  of  Gibbons'  Decline 
and  Fall  of  the  Roman  Empire  and  too  little  like  the 
headlines  of  the  New  York  Journal  and  the  Boston 
American. 

Another  problem  on  the  educational  side  of  this 
matter  lies  within  the  medical  profession  itself.  It  is 
a  pretty  good  saying  about  the  mote  in  our  brother's 
eye  and  the  beam  in  our  own  eye,  and  I  think  there 
are  several  beams  to  be  removed  from  the  ocular 
apparatus  of  the  medical  profession.  There  is  a  certain 
type  of  physician, — there  are  really  three  separate 
types,  sometimes  occuring  in  different  individual  physi- 
cians and  sometimes  rolled  into  one  man,  who  then  is 
a  dangerous  person.  These  are  the  "wait-and-see" 
cancer  doctor,  the  "diagnose-it-by-the-appearance-of-the- 
throat"   doctor  and  the   "opiate-for-a-cough"   doctor. 

I  do  not  know  how  many  of  you  have  had  the 
experience,  but  to  me  it  is  disheartening  to  go  into  a 
cancer  clinic  and  run  over  the  individual  case  histories 
that  you  see  there  on  the  specimen  jars.  For  instance, 
Dr.  So  and  So  treated  this  case  for  chronic  indigestion, 
then  referred  it  as  a  possible  cancer  of  the  stomach; 
another  watched  a  "lump"  in  the  breast  for  eighteen 
months,  and  then  thought  exploratory  extirpation  was 
perhaps  the  admissible  thing.  And  so  we  have  this 
tremendous  possibility  of  educating  the  medical  pro- 
fession. 


22 

Outside  of  that  there  is  another  field  among  the 
members  of  what  may  be  called  the  ancillary  healing 
professions  from  whom  the  general  public  receive  a 
great  deal  of  advice,  some  good  and  some  bad.  These 
professions  comprise  pharmacists,  dentists,  and  nurses. 
We  would  be  neglecting  a  great  item  in  our  campaign 
in  the  medical  profession  if  we  failed  to  impress  on 
these  other  professions  that  we  should  teach  them  much 
more  than  the  general  public  and  only  one  degree  less 
than  the  medical  profession  itself.  They  must  be  taught 
to  realize  that  these  suspicious  cases  should  be  referred 
to  surgeons  competent  to  give  advice. 

There  is  one  other  little  point,  not  a  great  one  at 
all,  but  perhaps  worthy  of  a  little  mention,  and  that 
is  the  question  of  cancer  lectures.  All  of  us  that  have 
had  any  experience  at  all  in  popular  lectures  on  tuber- 
culosis have  noted  that  the  public  begins  to  exhibit 
after  a  little  while  a  great  deal  of  mental  hysteria  in 
reference  to  tuberculosis  lectures.  I  am  not  certain 
about  this  in  regard  to  cancer;  I  do  not  know  that  any 
cultivation  of  this  fear  of  cancer  is  lost  effort,  and 
perhaps  it  is  perfectly  safe  to  scare  the  people  on  that 
subject,  but  on  the  other  hand,  I  have  had  a  little  exper- 
ience myself,  and  I  don't  think  it  is  very  easy  to  take 
a  general  mixed  audience  and  make  a  cancer  talk 
exactly  fascinating.  Some  can  do  it,  but  it  is  difficult. 
Dr.  Wood  spoke  of  the  work  he  did  in  Vermont,  but 
perhaps  there  is  a  more  appreciative  field  in  Vermont 
where  the  age  limit  is  higher.  WTe  started  to  put  out 
an  individual  lecture  on  cancer,  but  it  was  a  sad  affair, 
and  we  finally  decided  to  combine  it  with  the  so-called 
"wear-and-tear"  diseases,  and  I  really  think  in  the  long 
run  we  can  get  more  of  these  simple  points  in  regard 
to  cancer  into  circulation  by  running  them  in,  so  to 
speak,  in  connection  with  some  other  things,  than  by 
calling  a  meeting  especially  for  cancer. 

These  very  simple  things  have  been  said  over  and 
over  again,  but  it  is  the  very  simplicity  of  them  that 


23 

really  appalls  us.  The  means  are  so  simple  that  it 
amounts  just  to  getting  our  fellow  citizens  to  realize 
and  follow  a  half  dozen  aphorisms.  The  possibilities 
of  such  education  are  so  great  that  they  challenge  our 
credence,  and  yet  we  conclude  that  if  carried  out  and 
acted  upon,  such  cancer  education  will  reduce  the  cancer 
mortality  by  at  least  33  per  cent.,  possibly  66  per  cent. 

When  we  have  through  these  simple  measures 
before  us  in  the  form  of  educational  work  such  great 
possibilities  of  saving  human  life,  when  we  consider 
this  greatly  increasing  and  needless  wasting  of  human 
life,  we  certainly  must  all  enlist  to  the  very  best,  of  our 
ability  in  the  cancer  campaign.  There  is  no  need  to 
make  expert  pathologists  of  our  wage  earners,  either, 
to  gain  our  ends. 

To  summarize,  I  have  jotted  down  these  few  things 
which  are  not  new  but  which  seem  to  me  pretty  nearly 
to  cover  the  educational  field:  First,  early  cancer  is 
curable;  second,  pain  is  a  late  symptom;  third,  any 
irritation  in  the  body  is  worthy  of  investigation;  fourth, 
any  lump  in  the  breast  and  any  discharge  after  the 
menopause  need  careful  investigation;  fifth,  any  external 
sore  especially  in  the  lip  should  be  examined  (and  in 
this  connection  we  cannot  say  that  any  age  is  absolutely 
immune  from  cancer) ;  and,  last,  the  truth  is  not  that 
surgery  is  the  risk,  which  is  what  the  public  believe,  but 
that  delayed  surgery  is  the  risk. 

The  problem  that  still  remains  is  how  to  get  it  over 
to  the  people.  There  was  one  other  aspect  that  was 
very  little  touched  upon  where  I  believe  that  Health 
Departments  do  have  a  rather  important  function,  and 
that  is  in  serving  in  a  sort  of  advisory  or  judicial 
capacity  to  the  general  public  concerning  quacks.  They 
can  do  more  service  to  the  public  in  these  lines.  And 
another  line  in  which  they  should  be  of  service  is  in 
quieting  people's  minds  when  they  get  one  of  these 
waves  of  excitement  over  some  new  cure. 


24 

Then,  too,  there  is  the  question  of  research.  Under 
certain  circumstances  possibly  something  of  that  sort 
is  justifiable  in  the  Health  Department,  but  remembering 
how  small  the  funds  are  and  remembering  how  great 
the  returns  from  infant  mortality  and  tuberculosis  work, 
it  seems  to  me  very  questionable  whether  many  Health 
Departments  are  justified  in  spending  one  cent  in  research 
work  for  cancer.  There  are  two  great  reasons  for  this; 
first,  the  field  is  well  covered  by  these  specially  endowed 
cancer  institutes  and  the  high  research  work  carried 
on  by  universities  and  medical  schools;  and  second, 
because  we  can  use  the  same  money  better  in  telling 
the  people  what  we  already  know  about  cancer. 


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